New ACGME Standards Limit First-Year Resident Work Hours
Medical Education Feature – November 2010
Tex Med. 2010;106(11):37-40.
By Ken Ortolon
Temple internist and medical oncologist Christian Cable, MD, remembers well the life of a first-year resident. He completed his own residency only a few years ago and, until recently, was associate program director for the internal medicine residency program at Texas A&M University Health Science Center College of Medicine/Scott & White Healthcare.
"They [the interns] will start their day on the internal medicine ward at about 6 in the morning. They'll round on the patients and take admissions during the day," Dr. Cable said. "And then at 6 o'clock at night, they have responsibility for night admissions. So they will be on call.
"So, 6 am to 6 pm and then 6 pm to 6 am, you're on call admitting patients for your team. And then even the next day, you're doing the follow-up care for those patients until about noontime," he continued. "So we routinely see interns have 30-hour shifts once or twice a week."
While that type of grueling schedule may have been a rite of passage for young doctors back in the day, it will be a thing of the past, thanks to new duty hour restrictions recently adopted by the Accreditation Council on Graduate Medical Education (ACGME). They take effect July 1, 2011.
Some medical educators praise rules on resident supervision and professionalism that accompany the new duty hour restrictions, but they add that the new work limits may hamper residency programs' ability to adequately train new physicians.
"We're going to obviously institute whatever we have to because we're going to follow the rules," said Thomas Blackwell, MD, associate dean for graduate medical education at The University of Texas Medical Branch (UTMB) in Galveston. "But I think many people in the medical community are very concerned that we're taking a good idea too far."
Also of concern is the prospect of an investigation of resident work hours by the Occupational Safety and Health Administration (OSHA).
Reassessing Duty Hours
In late September, ACGME adopted the new resident training program standards recommended earlier this year by a task force that was created to reassess standards that were approved in 2003. Those earlier standards had, for the first time, implemented duty hour restriction for all residency programs in all specialties, limiting residents to working no more than 80 hours per week averaged over a four-week period.
The new standards do not alter the 80-hour limit, but medical educators say the new rules make two changes that could have a dramatic impact on many residency programs:
- First-year residents, or interns, will be allowed to work no more than 16 hours per day.
- All resident moonlighting must be counted toward the 80-hour limit, not just moonlighting done within the institution where the resident's training is occurring.
In addition to the hour work changes, the new standards also beef up resident supervision requirements, especially for interns, and add new requirements on professionalism for all members of the residency program team. For example, the new standards require appropriate degrees of faculty supervision of all patient care that residents provide, and mandate close oversight of first-year residents by more experienced physicians.
In a news release issued when the task force's recommendations were unveiled in June, ACGME said the new standards better match work hours and supervision with residents' level of experience and emerging competencies, advancing both graduate medical education and quality patient care.
"Patient safety and an excellent humanistic learning environment are the ACGME's twin prime objectives. The more closely the task force examined these related issues, the clearer it became that they were influenced by much more than just duty hours," said Thomas Nasca, MD, chief executive officer of ACGME and vice chair of the task force. "And we recognized that a 'one size fits all' set of standards didn't make sense."
The standards establish new categories of requirements for teamwork, clinical responsibilities, communication, professionalism, personal responsibility, and transition of care.
Lois Bready, MD, associate dean for graduate medical education at The University of Texas Health Science Center at San Antonio, was a member of the ACGME task force and says the reassessment of the 2003 standards had been contemplated for some time.
"When the duty hour restrictions were introduced, the plan at that time was to evaluate again in five years and see how they affected graduated medical education, to determine whether those requirements were sufficiently protective of patients and residents, and if residents were getting the education and experience they needed," she said.
The ACGME task force looked at the work hour rules from a patient safety perspective, as did a study in 2007 and 2008 by the Institutes of Medicine (IOM). The Agency for Healthcare Research and Quality requested that study.
Dr. Bready says the IOM study included little input from academic physicians involved in graduate medical education, with more testimony from patient safety organizations and the union that represents residents, the Committee for Interns and Residents (CIR).
By contrast, Dr. Bready says the ACGME task force heard testimony not only from patient safety experts, sleep specialists, CIR, and the American Medical Student Association (AMSA), but also from virtually all specialty societies.
"We tried to do it right," she said. "We didn't want to be reactive to the IOM. We wanted to look at the big picture, to take into account patient safety now but also to look at patient safety of the future. It's important that we train our residents well now so that they can deliver good care 10, 20, 30 years going forward."
Texas Medical Association President Susan Rudd Bailey, MD, served on an American Medical Association committee that studied resident work conditions, call schedules, and duty hours as far back as 1984. She says the seeds of concern planted then have taken a long time to germinate.
"My hope is the new ACGME work hour standards will provide an environment that enables residents to receive the educational experience they need and promote patient safety at the same time," Dr. Bailey said.
Choking on Duty Hours
Dr. Bready says the real "new ground" in the new standards involve supervision and professionalism. But those who run Texas residency programs says those standards do not vary that much from what Texas programs do now and will be easy to meet. Their concern largely centers on the new duty hour limits for interns.
"The idea that most people are choking on is the work hour exclusion for interns," said Dr. Cable, the director of the medical oncology fellowship program at Texas A&M University Health Science Center and a member of the TMA Council on Medical Education. "That's going to provide the greatest challenge for residency programs in Texas."
John Gill, MD, program director for the Waco Family Medicine Residency Program, is concerned about the quality of training the first-year residents will receive under the new standard.
"We are very concerned that an intern trained with these limitations simply won't have seen and cared for enough patients during their first year to be capable of handling the responsibilities we expect of a second-year resident, effectively turning our second-year residents into functional first years," he said.
Dr. Blackwell, who oversees 55 residency programs at UTMB, adds that the standards could threaten to break up the health care team.
"The intern is going home after 16 hours. The resident is staying 24 hours," he said. "What that really winds up doing is taking some of the responsibility for the patient off the intern and putting it on the resident, when they ought to be doing it more as a team. Historically, the way we work is we've had upper-level and lower-level residents work together, with the upper-level resident helping the lower-level resident make sure they do the right thing."
While some groups that represent residents and medical students support tougher restrictions of resident work hours, third-year family practice resident Travis Bias, DO, one of the chief residents at the Memorial Family Medicine Residency Program in Sugar Land, says many residents have serious concerns that the new limits will increase the possibility of errors because of increased patient hand-offs from shift to shift.
"The new 16-hour maximum work shift for interns will essentially force all programs still with traditional call to switch to a pure night float system," said Dr. Bias, the resident representative on the TMA Board of Trustees. That means more hand-offs of patient care because the day-shift interns will have to hand off their patients to a separate night shift, and the night shift likely will hand them off again in the morning.
Under the traditional system, those interns often would follow their patients for at least 24 hours and possibly as much as 30 hours, Dr. Bias says.
"With those increased hand-offs, there's been shown to be an increase in errors," he said.
He also says residents are concerned the new rules could force longer residencies in some specialties – particularly surgical specialties – because they cannot see as many patients as they used to.
"Right now, neurosurgery is a seven-year residency," Dr. Bias said. "But if you're only getting X number of procedures because your work hours are limited, then people are worried you're going to start tacking years onto that."
Drs. Gill, Blackwell, and Bready also recognize that the new restrictions will have a significant financial impact on residency programs and teaching hospitals as they try to determine who will do the work formerly done by the interns.
The options, they say, are to shift more care to the senior residents, expand residency slots to bring in more trainees to provide the care, hire more faculty physicians or hospitalists to care for patients, or rely more on midlevel providers, such as nurse practitioners and physician assistants, to provide care. None of those options are cheap, they say.
So, in a time when universities across the country are fairly tight on money, this could cost us significantly more," Dr. Blackwell said.
Dr. Gill also points out that ACGME will now require annual site visits to ensure all residency programs are adhering to the new standards. The Wall Street Journal has estimated those site visits could cost institutions $12,000 to $15,000 each.
The impact, however, likely will not be felt across the board. Some programs – such as dermatology and pathology – don't have as much pressure for late-night emergency care, so they will be better able to deal with the restrictions. Surgical and other residencies, however, will be hard pressed to find ways to provide the necessary coverage, the physicians say.
ACGME vs. IOM
Medical educators say the ACGME standards will present significant challenges, but some groups are not content to stop there. While the ACGME task force recommended a 16-hour daily work limit only for interns, the IOM recommended a 16-hour limit for all residents. Dr. Bready says CIR, the consumer watchdog group Public Citizen, and AMSA have petitioned OSHA to implement the IOM recommendations in their entirety.
She says the task force felt the IOM recommendation to limit all residents to 16-hour workdays was "unsupported" by the scientific evidence regarding impact on patient safety.
"We made serious efforts to protect the interns but also to allow the more senior learners to have the opportunity to gain experience that they would need to be able to work effectively the day they go out into practice," she said. "All physicians complete residency, and then they're expected to be able to practice competently and independently. And if you've never had that opportunity, it's difficult to know that you can, and it's difficult for the patients to know that you can. So the new rules intentionally provide greater duty hour flexibility at the more senior levels of residency."
In a Sept. 16 letter to OSHA, American Medical Association Executive Vice President and Chief Executive Officer Michael D. Maves, MD, MBA, said AMA "strongly believes that the ACGME is the appropriate body to regulate and monitor resident duty hours."
However, in late September, OSHA said it is examining the request that it investigate whether resident physicians are required to work too many hours, thus jeopardizing the safety of themselves and their patients.
"We are very concerned about medical residents working extremely long hours, and we know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors, and motor vehicle accidents," said David Michaels, PhD, assistant secretary of labor for occupational safety and health.
"The relationship of long hours, worker fatigue, and safety is a concern beyond medical residents, since there is extensive evidence linking fatigue with operator error," he said. "In its investigation of the root causes of the BP Texas City oil refinery explosion in 2005, in which 15 workers were killed and approximately 170 injured, the U.S. Chemical Safety Board identified worker fatigue and long work hours as a likely contributing factor to the explosion. It is clear that long work hours can lead to tragic mistakes, endangering workers, patients, and the public. All employers must recognize and prevent workplace hazards. That is the law. Hospitals and medical training programs are not exempt from ensuring that their employees' health and safety are protected."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon.
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